Professional Documents
Culture Documents
Case Study-Congestive Heart Failure
Case Study-Congestive Heart Failure
College of Nursing
Cebu City
__________________________________________
___________________________________________
___________________________________________
Presented by
TANGCALAGAN, Kent C.
TONZO, Hope Glysdi
TUMAMUT, Yvenette Kris
UY, Justin Earl
VILLAMIL, Molly
YBAÑEZ, Ma. Doreen
BSN-III Block 8
__________________________________________
Presented to
Aeda Mae Siao, RN
Clinical Instructor
__________________________________________
April 19-23; 26-30, 2010
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I. INTRODUCTION
1. Cause
HF may result from a number of causes like cardiac compensatory
mechanisms, other dysfunctions and other disorders of the heart.
Cardiac compensatory mechanisms (increases in heart rate,
vasoconstriction, and heart enlargement) occur to assist the struggling
heart.These mechanisms are able to compensate for the heart's
inability to pump effectively and maintain sufficient blood flow to
organs and tissue at rest. Physiologic stressors that increase the
workload of the heart (exercise, infection) may cause these
mechanisms to fail and precipitate the clinical syndrome associated
with a failing heart (elevated ventricular/atrial pressures, sodium and
water retention, decreased CO, circulatory and pulmonary congestion).
The compensatory mechanisms may hasten the onset of failure
because they increase afterload and cardiac work.
Two types of dysfunction may exist with heart failure (see Figure
13-5). Systolic failure: poor contractility of the myocardium resulting in
decreased CO and a resulting increase in the systemic vascular
resistance. The increased SVR causes an increase in the afterload (the
force the left ventricle must overcome in order to eject the volume of
blood). Diastolic failure: stiff myocardium, which impairs the ability of
the left ventricle to fill up with blood. This causes an increase in
pressure in the left atrium and pulmonary vasculature causing the
pulmonary signs of heart failure.
It may also be caused by disorders of heart muscle resulting in
decreased contractile properties of the heart.
Elevated preload can be caused by incompetent valves, renal
failure, volume overload, or a congenital left-to-right shunt. Elevated
afterload occurs when the ventricles have to generate higher pressures
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2. Risk Factors
GENETIC CONSIDERATIONS
HF is a complex disease combining the actions of several genes
with environmental factors. Many HF risk factors have genetic causes
or are associated with genetic predispositions. These include
hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy
(DCM), coronary artery disease, myocardial infarction, and
hypertension. Genetic polymorphisms of the reninangiotensin-
aldosterone system (RAAS) and sympathetic system have also been
associated with susceptibility to and/or mitigation of HF. Gene variants
in the alpha-2c adrenoceptor and the alpha-1 adrenoceptor have been
associated with a higher risk of HF among African Americans.
d) Epidemiology or Statistics
UNITED STATES
As with coronary artery disease, the incidence of HF increases with
age. However, the rate of coronary artery disease is decreasing and
just the opposite is true for HF. Nearly 5 million people in the United
States have HF, with more than one-half million new cases diagnosed
each year (American Heart Association, 2001). The prevalence rate of
HF among non-Hispanic whites 20 years of age or older is 2.3% for
men and 1.5% for women; for non-Hispanic blacks, the rates are 3.5%
and 3.1%, respectively (American Heart Association, 2001). HF is the
most common reason for hospitalization of people older than age 65
and the second most common reason for visits to a physician’s office.
The rate of readmission to the hospital remains staggeringly high. The
rise in the incidence of HF reflects the increased number of elderly and
improvements in treatment of HF resulting in increased survival rates.
However, the economic burden caused by HF is estimated to be more
than 23 billion dollars in direct and indirect costs and is expected to
increase (American Heart Association, 2001). Many hospitalizations
could be prevented by improved and appropriate outpatient care.
PHILIPPINES
In the Philippines, HF is the fastest-growing cardiac disorder and it
affects 2% of the population. Almost 1 million hospital admissions
occur each year for acute decompensated HF, and the rehospitalization
rates during the 6 months following discharge are as much as 50%. In
spite of recent advances in the treatment of HF, the 5-year estimated
mortality rate is almost 50% (Department of Health, 2005).
e) Assessment Highlights
HISTORY
Patients with HF typically have a history of a precipitating factor
such as myocardial infarction, recent open heart surgery,
dysrhythmias, or hypertension. Symptoms vary based on the type and
severity of failure. Ask patients if they have experienced any of the
following: anxiety, irritability, fatigue, weakness, lethargy, mild
shortness of breath with exertion or at rest, orthopnea that requires
two or more pillows to sleep, nocturnal dyspnea, cough with frothy
sputum, nocturia, weight gain, anorexia, or nausea and vomiting. Take
a complete medication history, and determine if the patient has been
on any dietary restrictions. Determine if the patient regularly
participates in a planned exercise program.
The New York Heart Association has developed a commonly used
classification system that links the relationship between symptoms and
the amount of effort required to provoke the symptoms.
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PHYSICAL EXAMINATION
Observe the patient for mental confusion, anxiety, or irritability
caused by hypoxia. Pale or cyanotic, cool, clammy skin is a result of
poor perfusion. In rightsided HF, the jugular veins may become
engorged and distended. If the pulsations in the jugular veins are
visible 4.5 cm or more above the sternal notch with the patient at a 45-
degree angle, jugular venous distension is present. The liver may also
become engorged, and pressure on the abdomen increases pressure in
the jugular veins, causing a rise in the top of the blood column.
This positive finding for HF is known as hepatojugular reflux
(HJR). The patient may also have peripheral edema in the ankles and
feet, in the sacral area, or throughout the body. Ascites may occur as a
result of passive liver congestion.
With auscultation, inspiratory crackles or expiratory wheezes (a
result of pulmonary edema in left-sided failure) are heard in the
patient’s lungs. The patient’s vital signs may demonstrate tachypnea
or tachycardia, which occur in an attempt to compensate for the
hypoxia and decreased CO. Gallop rhythms such as an S3 or an S4,
while considered a normal finding in children and young adults, are
considered pathological in the presence of HF and occur as a result of
early rapid ventricular filling and increased resistance to ventricular
filling after atrial contraction, respectively. Murmurs may also be
present if the origin of the failure is a stenotic or incompetent valve.
PSYCHOSOCIAL
Note that experts have found that the physiological measures of HF
(such as ejection fraction) do not always predict how active, vigorous,
or positive a patient feels about his or her health; rather, a person’s
view of health is based on many factors such as social support, level of
activity, and outlook on life.
f) Diagnostic Procedures
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g) Management
The basic objectives in treating patients with HF are the
following: eliminate or reduce any etiologic contributory factors,
especially those that may be reversible, such as atrial fibrillation or
excessive alcohol ingestion; and, reduce the workload on the heart by
reducing afterload and preload.
MEDICAL MANAGEMENT
Managing the patient with HF includes providing general
counseling and education about sodium restriction, monitoring daily
weights and other signs of fluid retention, encouraging regular
exercise, and recommending avoidance of excessive fluid intake,
alcohol, and smoking. Medications are prescribed based on the
patient’s type and severity of HF. Oxygen therapy is based on the
degree of pulmonary congestion and resulting hypoxia. Some patients
may need supplemental oxygen therapy only during activity.
Others may require hospitalization and endotracheal intubation.
If the patient has underlying coronary artery disease, coronary artery
revascularization with percutaneous transluminal coronary angioplasty
(PTCA) or bypass surgery may be considered. If the patient’s condition
is unresponsive to advanced aggressive medical therapy, innovative
therapies, including mechanical assist devices and transplantation,
may be considered.
Cardiac resynchronization, involving the use of left ventricular
and biventricular pacing, is a treatment for HF with electrical
conduction defects. Left bundle branch block (LBBB) is frequently
found in patients with systolic dysfunction. LBBB occurs when the
electrical impulse, which normally depolarizes the right and left bundle
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branches at the same time, depolarizes the right bundle branch but not
the left bundle branch. The dyssynchronous electrical stimulation of
the ventricles causes the right ventricle to contract before the left
ventricle, which can lead to further decreased ejection fraction (Gerber
et al., 2001). Use of a pacing device (eg, Medtronic InSync), with leads
placed on the inner wall of the right atrium and right ventricle and on
the outer wall of the left ventricle, provides synchronized electrical
stimulation to the heart. In one study, 63% of the patients who had
received these devices showed improvement in clinical status,
including NYHA functional class and global assessment, compared with
38% of placebo patients (Abraham, 2002).
PHARMACOLOGICAL MANAGEMENT
Several medications are indicated for systolic HF. Medications for
diastolic failure depend on the underlying condition, such as
hypertension (see Chap. 32) or valvular dysfunction (see Chap. 29).
If the patient is in mild systolic failure, an ACE inhibitor usually is
prescribed. If the patient is unable to continue an ACE inhibitor (eg,
because of development of renal impairment as evidenced by elevated
serum creatinine or persistent serum potassium levels of 5.5 mEq/L or
above), an angiotensin II receptor blocker (ARB) or hydralazine and
isosorbide dinitrate are considered as part of the treatment plan. A
diuretic is added if signs of fluid overload develop. Digitalis is added to
ACE inhibitors if the symptoms continue. Although previously
contraindicated in HF, specific beta-blockers decrease mortality and
morbidity if added to the initial medications. Spironolactone, a weak
diuretic may also be added for persistent symptoms.
(Brater, 1998). Both types of diuretics may be used for those in severe
HF and unresponsive to a single diuretic. These medications may not
be necessary if the patient responds to activity recommendations,
avoidance of excessive fluid intake (<2 quarts/day), and a lowsodium
diet (eg, <2 g/day).
Spironolactone (Aldactone) is a potassium-sparing diuretic that
inhibits sodium reabsorption in the late distal tubule and collecting
duct. It has been found to be effective in reducing mortality and
morbidity in NYHA class III and IV HF patients when added to ACE-Is,
loop diuretics, and digoxin. Serum creatinine and potassium levels are
monitored frequently (eg, within the first week and then every 4
weeks) when this medication is first administered. Side effects of
diuretics include electrolyte imbalances, symptomatic hypotension
(especially with overdiuresis), hyperuricemia (causing gout), and
ototoxicity. Dosages depend on the indications, patient age, clinical
signs and symptoms, and renal function. Table 30-4 lists commonly
used diuretics, dosages, and pharma cokinetic properties. Careful
patient monitoring and dose adjustments are necessary to balance the
effectiveness with the side effects of therapy. Diuretics greatly
improve the patient’s symptoms, but they do not prolong life.
NUTRITIONAL MANAGEMENT
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SURGICAL MANAGEMENT
If the elevated preload is caused by valvular regurgitation, the
patient may require corrective surgery. Corrective surgery may also be
warranted if the elevated afterload is caused by a stenotic valve.
Another measure that may be taken to reduce afterload is an intra-
aortic balloon pump (IABP). This is generally used as a bridge to
surgery or in cardiogenic shock after acute myocardial infarction. It
involves a balloon catheter placed in the descending aorta that inflates
during diastole and deflates during systole. The balloon augments
filling of the coronary arteries during diastole and decreases afterload
during systole. IABP is used with caution because there are several
possible complications, including dissection of the aortoiliac arteries,
ischemic changes in the legs, and migration of the balloon up or down
the aorta.
OTHER MEASURES
Other measures the physician may use include supplemental
oxygen, thrombolytic therapy, percutaneous transluminal coronary
angioplasty, directional coronary atherectomy, placement of a
coronary stent, or coronary artery bypass surgery to improve oxygen
flow to the myocardium. Finally, a cardiac transplant may be
considered if other measures fail, if all other organ systems are viable,
if there is no history of other pulmonary diseases, and if the patient
does not smoke or use alcohol, is generally under 60 years of age, and
is psychologically stable.
IMPROVING OXYGENATION
Raise head of bed 8 to 10 inches (20 to 30 cm) reduces venous
return to heart and lungs; alleviates pulmonary congestion. Support
lower arms with pillows to eliminate pull of their weight on shoulder
muscles. Sit orthopneic patient on side of bed with feet supported by a
chair, head and arms resting on an over-the-bed table, and
lumbosacral area supported with pillows.
Auscultate lung fields at least every 4 hours for crackles and
wheezes in dependent lung fields (fluid accumulates in areas affected
by gravity). Mark with ink that does not easily rub off, the level on the
patient's back where adventitious breath sounds are heard. Use
markings for comparative assessment over time and among different
care providers. Observe for increased rate of respirations (could be
indicative of falling arterial pH). Observe for Cheyne-Stokes
respirations (may occur in elderly patients because of a decrease in
cerebral perfusion stimulating a neurogenic response). Position the
patient every 2 hours (or encourage the patient to change position
frequently) to help prevent atelectasis and pneumonia. Encourage
deep-breathing exercises every 1 to 2 hours to avoid atelectasis.
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CONTROLLING ANXIETY
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MINIMIZING POWERLESSNESS
Patients need to recognize that they are not helpless and that
they can influence the direction of their lives and the outcomes of
treatment. The nurse assesses for factors contributing to a sense of
powerlessness and intervenes accordingly. Contributing factors may
include lack of knowledge and lack of opportunities to make decisions,
particularly if health care providers and family members behave in
maternalistic or paternalistic ways. If the patient is hospitalized,
hospital policies may promote standardization and limit the patient’s
ability to make decisions (eg, what time to have meals, take
medications, prepare for bed).
Taking time to listen actively to patients often encourages them
to express their concerns and ask questions. Other strategies include
providing the patient with decision-making opportunities, such as when
activities are to occur or where objects are to be placed, and
increasing the frequency and significance of those opportunities over
time; providing encouragement while identifying the patient’s
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II. OBJECTIVES
a) General
After 1-3 hours of case presentation in the medical ward, the
students will be able to develop and apply specific knowledge,
skills and attitude on the disease process of Congestive Heart
Failure generally on the body; anticipate and provide effective
nursing care; and, deliver specific interventions needed to treat the
disease.
b) Specific
1. Nurse-Centered Objectives
Upon completion of this case study, the student nurse should be able to:
a) Make a thorough assessment about the patient’s personal history,
family background and lifestyle
b) Cite factors that contribute to the patient’s condition.
c) Review the anatomy and physiology of the integumentary system.
d) Explain the histopathology and pathogenesis of Congestive Heart
Failure.
e) Make a comprehensive nursing care plan and its intervention.
f) Impart knowledge to the patient regarding on his condition
g) Evaluate patient’s response towards rendered care given by the
student nurse.
2.Patient-Centered Objectives
Upon completion of this case study, the Guest should be able to:
a) Establish rapport and trusting relationship with the student nurse.
b) Give information about self, family and past experiences.
c) Cooperate on management prepared by the student nurse.
d) Verbalize feelings and thoughts of his present condition.
e) Understand awareness of his disorder.
f) Know the possible causes of the disorder.
g) Learn and understand why such laboratory examinations are being
done.
h) Apply the learned self-care measures to improve well-being.
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a) Client Profile
A case of Patient MR, 33 years old, female, married, Filipino
citizen, a Roman Catholic, housewife and presently living in Paknaan,
Mandaue City was assessed last April 23, 2010 by 4:30am at the
Evvesley Childs Sanitarium (Female Medical ward). Client was admitted
last April 19, 2010 at around 12:00 a.m via Taxi accompanied by her
eldest son with admitting complaints of shortness of breath, dizziness
and fatigue. Admitting V/S is as follows: T-37.9; PR-92; RR-25; BP-
200/160. She's under the care of Dr. Lagora. Patient was transferred to
the Female Medical Ward at 4:10 am of the same day. Patient claimed
to be hypertensive but not diabetic or asthmatic. Patient is neither a
smoker nor an alcoholic beverage drinker. She has no known allergies
to drug as well as to foods; but, since she has a heart problem, she ate
less on restricted foods high in cholesterol.
d) Developmental History
According to Sigmund Freud Psychosexual Stage, Patient MR is in
the Genital phase. This stage represents the major portion of life, and
the basic task for the individual is the detachment from the parents.
Patient is already living with her own family. In this stage the focus on
the genitals, the energy is expressed with adult sexuality. Patient
claimed to be sexually active. The ego in the genital stage is well-
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e) Environmental History
Patient MR is currently residing in Paknaan Mandaue City Cebu.
She together with her family with three children are living in a rented
house and lot nearby the street side which is made out of mixed
materials. They have two bedrooms, a dining area and a living room.
Their toilet is a manual flush type, they have electricity and have their
own water source. Patient MR disposes their garbage through garbage
trucks which collects their trash during Mondays and Thursdays. They
use plastic bags and old barrels for garbage containers. They have one
dog and a cat as their pet. The patient claimed that there is no
difficulty in seeking healthcare because of the distance from the health
center is not that far approximately 5km. Patient MR also has no
problems with going to Church and to the market which is only 2km
away from their house. Patient MR has a quiet type of personality but
though such, she can still manage to talk to some friends and mingle
with her neighbors from time to time.
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2. Nutritional/ Metabolic
PTA, the patient’s usual diet from breakfast, lunch and dinner is
composed of rice, side dish of fish in varied preparation, vegetables and
meat. She can consume 7-9 glasses a day.
During admission, Patient’s current dietary status is DAT. She reported
during on her 24-hour diet recall that she had been eating a cup of
coffee and bread for breakfast, a cup of rice and fish for lunch, and a cup
of rice and a vegetable soup for dinner. She was not aware of the effects
of an increase in sodium and fat intake to her CHF. She stated that she
did not take vitamin supplements because they are expensive. She
reported adequate fluid intake, drinking 1-2 cups of coffee daily and
along with two 5-7 glasses of water. She had recently experienced a 5-8
lb weight gain as a result of her CHF. She did not report any changes in
appetite or difficulty chewing but have difficulty swallowing. Her diet
restrictions were low sodium and low fat because of her CHF and cardiac
history. She reported experiencing occasional nausea and loose stools.
She was 5’6” and 165 pounds. Her prescribed diet was a cardiac diet.
She had no enteral feeding or NG tube, and her IV was 500mL D5W
running at 10ggts/min.
3. Elimination
Prior to admission, patient experiences 1-2 bowel movements per day
and usually voids 4-5 times a day with estimates 200ml per urination.
During admission, the patient was fully functional in the elimination
pattern. She reported urinating three to four times daily with no
difficulty and no recent change in her urinary pattern. She had a bowel
movement the day of our interview, and reported moving her bowels
daily, sometimes twice. She denied changes in this pattern. Her fluid
balance was improving, with an intake total of 200 mL and an output
total of 500 mL in the entire shift. Her urine was clear and yellow, and
her abdomen was soft with active bowel sounds in all four quadrants.
She was fully continent with experience profuse sweating.
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4. Activity/ Exercise
Prior to admission, patient complains about her low stamina. She can’t
tolerate strenuous activities. Her ADL includes washing clothes, doing
household chores and cleaning the backyard. As a past time she
watches television with her children during late afternoon.
During admission, Patient was weak and needs assistive devices. She
reported don’t have sufficient energy to perform activities due to
fatigue. She reported feeling shortness of breath, fatigue, and
palpitations related to her CHF. She reported exercising daily by walking
or swimming, and doing her household chores. She needed assistance
with her ADL’s and to keep herself well groomed. She had a limited
range of motion and her tone and strength were symmetrical in all
extremities. She had a steady gait. Her respiratory rate was 28 with
normal, symmetrical breaths. O2 was placed through nasal cannula
regulated at 4 L. She had fine inspiratory and expiratory crackles
posteriorly througout. Her apical pulse was 70 and irregular due to a-fib,
and her BP was 119/59. She had +2 strength radial pulses and +1
strength pedal pulses. Her capillary refill was less than 3 seconds and
her extremities were warm and pink. Risk for falls is the main nursing
diagnosis in this health pattern due to fatigue.
5. Sleep/ Rest
PTA, patient has an approximately 3-4 hours of sleep. Client usually
wakes at 6am. Client’s problemof the very small number of hours of
sleep is due to nocturnal paroxysmal dyspnea. Patient sometimes have
short naps in the afternoon.
During admission, she reported sleeping about 4 hours per night and
feeling well rested during the day. She reported having occasional
difficulty falling asleep for which she sometimes used milk as sleeping
aid. She took occasional naps after her walk or during soap operas in the
afternoon. She did exhibit lethargy and irritability and during night times
due to SOB and nocturnal paroxysmal dyspnea. Her diagnosis in this
area is risk for disturbed sleep pattern related to difficulty falling asleep
at night.
6. Cognitive/ Perceptual
Patient can decode simple instructions such as advising her to change
her position or clothes. She was functional in this health pattern. She
had no real visual difficulties other than wearing glasses and no hearing
problems. She reported occasional difficulty with her short term
memory; things like word and name recall. She said that the easiest way
for her to learn things is to do them herself and she did not like being
waited on. She did not report any numbness, tingling or pain in her
extremities. She was at some risk for impaired short term memory
related to her age.
Client is not able to read the text of the calendar and writings from
chart half a meter away. The client has difficulty to follow the pen placed
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7. Sexuality/ Reproductive
Client has an obstetric history of G3P3. Client has an irregular
menstrual cycle with menses appearing once in two-three months. She
was noted menarche at the age of 13. The client speaks of single
partner sexual contact to date. Client experienced sexual contact with
husband at the age of 22 y.o. with her husband. She stated that her
sexual relationship with her husband was satisfying, and that sexual
intercourse had been limited for a while due to dypnea during strenuous
activity. The client uses contraceptives such as pills from 2005-2008.
She verbalizes that sexual activity should be in the context of marriage.
Client expresses no concern, abuse or problems regarding illness and
sexual patterns. She uses 3-4 napkin pads per day. Thelarche began at
10 years of age. Menarche was experienced during 13 years of age.
Client verbalizes no history of sexually related illnesses or problems is
currently in UTI. The client is not aware of the importance of self breast
examination; and, consents that she never performed it.
8. Self-Perception/ Self-Concept
Her recent job is a factory worker. She currently was retired. She
described herself as determined and stubborn and said she liked to do
things herself and ask for help if she needed it. She stated the feeling of
emptiness sometimes. She said that her recent illness had not changed
her self image and that it had only motivated her to get better. She said
she felt angry/annoyed when she was not in control and experienced
occasional heart palpitations when she felt anxious or fearful. Her
children and grandchildren had been challenging for her recently, and
she reported feeling depressed when she couldn’t help them out with
their various issues in life. She said that she sometimes feels weak; she
was powerless or had lost hope. She had excellent eye contact and
conversational skills.
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9. Role-Relationship Pattern
She was fully functional in this pattern. She was married and lived with
her husband, and they had three daughters. She reported that they had
no financial concerns. She said that she turns to her older daughter for
support. She was very assertive and noticed everything that went on
during her hospital stay. She was not afraid to point out when she felt
something was not right or could be improved.
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V. Physical Assessment
GENERAL APPEARANCE:
Patient seen lying on bed, awake, alert, responsive, coherent, afebrile,
with venoclysis of # 3 D5 Water, infusing well at right hand with the
following vital signs: T- 38 C, BP – 180/90, PR – 98 bpm, RR – 28 cpm
Head
Head is rounded with smooth skull contour. Nodules and masses
are absent. Hair is evenly distributed, black in color, and with smooth
texture. Facial feature is symmetric, palpebral fissures equal in size
and symmetric nasolabial folds. Facial movements are symmetric.
Eyes
Hair in eyebrow is evenly distributed, skin is intact,
symmetrically aligned, moves equally. Eyelashes are equally
distributed, curled slightly outward. Skin are intact on eyelids, absence
of discharge, and no discoloration. Lids close symmetrically. When lids
open, no visible sclera above corneas, and upper and lower borders of
cornea are slightly covered. Conjunctiva is transparent, capillaries are
evident, and sclera is white. Palpebral conjunctiva is shiny, smooth and
pink in color. Lacrimal gland has no edema and no tenderness. Cornea
is transparent, shiny and smooth. Patient blinks when the cornea is
touched. Pupils are black in color, equal in size, round, and smooth. Iris
is flat and round. Patient can see objects in the periphery. Both eyes
are coordinated, moves in unison with parallel alignment. Light
reflection appears at symmetric spots in both eyes.
Ears
Color is the same as the face. Position is symmetric. Auricles are
mobile, firm and not tender. Pinna recoils after it is folded. Tympanic
membrane is pearly gray in color and semitransparent. Cerumen is wet
and brown in color. Both ears can hear normal voice tones.
Nose
Symmetric and straight, no discharge or flaring. No tenderness
noted and lesions are absent. Air moves freely as the patient breath
through the nares. The mucosa of the nasal cavities is pink with clear
watery discharge. Lesions are absent. Nasal septum is intact and in
midline. Facial sinuses are not tender, well outlined, contain air and
light up equally.
Neck
Neck muscles are equal in size and head is centered. Head
movement is coordinated with smooth motion without discomfort.
Nodes are not palpable on the entire neck. Trachea is centrally placed
in midline of the neck with space equal on both sides. Thyroid gland is
not visible upon inspection. Gland ascends upon telling the patient to
swallow but is not visible. Gag reflex is present.
Heart
Pulsations are absent on the aortic and pulmonic areas.
Pulsations are present on the tricuspid area. Upon auscultation of the
heart on the aortic, pulmonic, tricuspid and apical, intensity is
increased. S3 is present.
Abdomen
Skin is unblemished on the abdomen, uniform in color, rounded,
and no evidence of enlargement of liver or spleen. The contour of
abdomen with reference to the foot is symmetric. Movement of the
abdomen while breathing is symmetric. Upon palpation, no tenderness
was noted with consistent tension. Liver is not palpable and border
feels smooth. Bladder is not palpable.
Musculoskeletal System
Muscle size is equal on both sides of the body. No contractures
were noted on the tendons and muscles. Upon palpation, muscles at
rest are atonic (lacking firm). Patient has slow, coordinated
P a g e | 34
MENTAL STATUS
Level of Consciousness
Patient is awake, alert and responds to verbal stimuli. She can
respond to questions simultaneously. Speaks clearly and uses
appropriate words. Patient can able to comprehend questions and
directions.
Awareness
Patient is oriented to time, place, and person by tactful
questioning. Patient was asked of the time of the day, the date and
names of family members.
Thought Process
Patient can recall three digit numbers that was asked to repeat.
She can still recall the things she has done within the day. Patient can
still recall information given earlier such as the name of the student
nurse. Patient is able to answer questions that need simple abstract
thinking. She can be able to perform simple mathematical calculations
and problem solving. Patient has sound judgment and can be able to
express her decisions and interests.
Communicating Process
Patient is able to use verbal and nonverbal communication such
as facial expression and hand gestures. She is able to use appropriate
affect and mood and able to use appropriate words when
communicating. Patient communicates in a an average page with
proper choice of words.
Cranial Nerve I
Patient is able to identify the smell of alcohol and perfume.
Cranial Nerve II
Patient can see the periphery when one eye is covered. Snellen chart
was not used in the assessment.
Cranial Nerve IV
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Cranial Nerve V
Patient’s blink reflex is positive through the use of cotton in touching
the sclera. Alternating blunt and sharp ends over client’s forehead
showed positive result.
Cranial Nerve VI
Eyes equally move, eyeballs move laterally.
Cranial Nerve IX
Swallowing ability is present and gag reflex. Patient is able to move her
tongue freely side to side and up to down.
Cranial Nerve X
Client’s speech has no hoarseness. Vibration on vocal chord is felt
upon palpation. Swallowing is also present.
Cranial Nerve XI
Head can extend to front, back and sides. Patient can shrug shoulder
against resistance from hand.
SENSORY FUNCTION
Patient is able to react on light and touch sensation. Patient is able to
discriminate between sharp and dull sensation. She can able to determine
one poin and two point objects being used. Patient can also discriminate
between hot and cold temperature. Patient can recognize objects being
placed on hands. She can also identify numbers and letters written on palm.
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P a g e | 37
HEMATOLOGY
Hemoglobin 04-20- 140- 120- 117 g/L A decrease implies
10 180 160 anemia, recent
g/L g/L hemorrhage and fluid
retention
Hematocrit 04-20- 0.42- 0.37- 0.35 g/L A decrease implies
10 0.52 0.47 anemia and
g/L g/L hemodilution
RBC 04-20- 4.7- 4.2- 4.4 /L A decreaseimplies
10 6.1 5.4 anemia and fluid
/L /L overload of >24 hours
WBC 04-20- 5-10 x /L 8.8 x /L Within normal range
10
Differential Count
Neutrophils 04-20- 40-74 % 84 % An increase implies
10 asthma, hay fever,
parasitic infections,
chronic myelocytic
leukemia, Hodgkin’s
disease and metastasis
Lymphocyt 04-20- 19-48 % 12 % A decrease implies no
es 10 significant
interpretation
Monocyte 04-20- 3-9 % 2% A decrease implies no
10 significant
interpretation
Eosinophil 04-20- 0-7 % 2% Within normal range
10
Basophil 04-20- 0-2 % 0% Withn normal range
10
URINE CHEMISTRY
Color 04-20- Straw to dark Dark Normal Result
10 yellow Yellow
Appearance 04-20- Clear Cloudy Turbity implies kidney
10 infection
Specific 04-20- Newborns: 1- 1.030 An increase implies
Gravity 10 1.02 nephritic syndrome
Infants: 1.002-
1.006
Adults: 1.016-
P a g e | 38
1.022
pH 04-20- 4.6-6.5 5.0 Within normal range
10
Protein 04-20- None (++) Presence implies
10 proteinuria, renal failure
or myeloma
Glucose 04-20- Negative Negative Normal result
10
RBC 04-20- 0 /hpf 0-2 2-4 /hpf Within maximum
10 /hpf normal range.
WBC 04-20- 0-2 0-5 10-12 /hpf An increase implies
10 /hpf /hpf trauma or tumors
Casts 04-20- Hyaline, Coarsely Normal result
10 coarse. granular.
Fine granular. 1-2 /hpf
RBC, WBC.
Waxy casts
Amorphous 04-20- Small amounts Few Normal result
Materials 10
Epithelial 04-20- Small amounts Few Normal result
Cells 10
Bacteria 04-20- None Many Presence implies GUT
10 infection or
contamination of
external genitalia
Other Procedures:
X-ray 04/20/10
Conclusion: Bilateral Pleural Effusion predominantly at the left.
Electrocardiograph 04/20/10
10 mm/ mV 25 mm/s
HF:DF HR=112 bpm
P a g e | 39
Anxiety related to
breathlessness and
restlessness from
inadequate oxygenation
Powerlessness related to
inability to perform role
responsibilities secondary
to chronic illness and
hospitalization.
b. Physical Ineffective airway
Assessment clearance related to
presence of
tracheobronchial
obstruction
Decreased Cardiac
Output related to
impaired contractility
and increased preload
and afterload.
THE HEART
The Heart
The heart is located in the thoracic cavity in the mediastinum, between the
lungs and deep to the sternum.
• Base – broad superior portion of the heart which is the point of
attachment for the great vessels
• Apex – inferior end that tapers to a blunt point immediately above the
diaphragm
The adult heart is about 9 cm wide at the base, 13 cm from base
to apex and 6 cm from anterior to posterior at its thickest point –
roughly size of one’s fist. Its weight is 300 g.
• Pericardium – a double-walled sac that encloses the heart
Parts:
- Parietal Pericardium – outer wall with thick superficial fibrous
layer and thin serous layer.
P a g e | 43
The Chambers
• Right and Left Atria – the thin- walled receiving chambers for blood
returning to the heart by way of the great veins. Each atrium has
a small earlike extension called auricle that slightly increases its
volume.
• Right and Left Ventricles – the pumps that eject blood into the arteries
And keep it flowing around the body. The right ventricle
constitutes most of the anterior aspect of the heart, while the left
ventricle forms the apex and inferoposterior aspect.
Sulci (grooves) – boundaries on the surface of the four chambers of the heart
Namely:
Coronary Sulcus – encircles the heart near the base and
separates the atria above the ventricles below.
Anterior Intraventricular Sulcus – extends obliquely down the
heart from the coronary sulcus toward the apex at the front
Posterior Intraventricular Sulcus - extends obliquely down the
heart from the coronary sulcus toward the apex at the back
The Valves
Atrioventricular (AV) Valves – regulate the openings between the atria
and the ventricles
Semilunar Valves – regulate the flow of blood from the ventricles into
the great arteries
Pulmonary Valve – controls the opening from the right ventricle into
the pulmonary trunk
Aortic Valve - controls the opening from the left ventricle into the
aorta
Blood returns to the heart through the two large veins, the superior
vena cava draining the head, neck, upper limbs and thoracic cavity, and the
inferior vena cava draining the abdominal cavity and lower limbs. Blood in
the right atrium flows through the right AV valve and into the right ventricle.
When the right ventricle contracts, the AV valve closes and blood is
forced through the pulmonary valve into the pulmonary trunk. This artery
ascends from the heart front of the heart and branches into the right and left
pulmonary arteries, which lead to the respective lungs. In the lungs, this
blood unloads its carbon dioxide and picks up a load of oxygen.
The oxygen-enriched blood returns by way of several veins which
converge to form four pulmonary veins by the time they reach heart. These
four empty into the left atrium. Blood flows from there past the left valve into
the left ventricle. The left ventricle contracts at the same time as the right,
and expels blood through the aortic valve into the ascending aorta. Blood in
the aorta flows to every organ in the body, unloading some of its O2 from the
tissues, and returning to the heart via the vena cavae.
Cardiac cycle is the term referring to all or any of the events related to the
flow or blood pressure that occurs from the beginning of one heartbeat to
the beginning of the next.
Heart Rate - the frequency of the cardiac cycle
Five Stages of 'beat' of the heart:
1. "Late diastole" which is when the semilunar valves close, the AV Valves
open and the whole heart is relaxed. Second,
2. "Atrial systole" when atria is contracting, AV valves open and blood
flows from atrium to the ventricle.
3. "Isovolumic ventricular contraction" it is when the ventricles begin to
contract, AV valves close, as well as the semilunar valves and there is
no change in volume.
4. "ventricular ejection", Ventricles are empty, they are still contracting
and the semilunar valves are open.
5. "Isovolumic ventricular relaxation", Pressure decreases, no blood is
entering the ventricles, ventricles stop contracting and begin to relax,
semilunars are shut because blood in the aorta is pushing them shut.
P a g e | 45
Myocyte (also known as a muscle cell) is the type of cell found in muscles.
They arise from myoblasts. Each myocyte contains myofibrils, which are
long chains of sarcomeres, the contractile units of the cell.
Stroke volume (SV) is the volume of blood pumped from one ventricle of
the heart with each beat. It is calculated by subtracting the volume of
blood in the ventricle at the end of a beat (called end-systolic volume)
from the volume of blood just prior to the beat (called end-diastolic
volume). This applies equally to both left and right ventricles of the heart.
These two stroke volumes are generally equal, both approximately 70 ml
in a healthy 70-kg man.
AGENT
HOST
GENES
Inappropriate Restricted Decreased
*Genetic methods placed filling on myocyte
Myocyte
predisposition on on the heart the heart loss contractility
hypertrophic
cardiomyopathy
(HCM) and dilated Decreased Decreased Increased
Systolic WHEN SLEEPING
relaxation elastic stiffness of the
cardiomyopathy dysfunction
Reduced Nocturnal recoil ventricle
(DCM), coronary Decreased adrenergic depression of
artery disease, stroke volume support of the respiratory Diastolic
myocardial ventricular center dysfunction
Decreased
function
infarction, and cardiac output
Increased left Rapid filling in
hypertension ventricular end- early diastole
* Genetic diastolic pressure S3, apical impulse is
hypertrophy Increased Increased
polymorphisms of catecholamine preload S4 displaced laterally
Paroxysmal
the release nocturnal Increased pulmonary
reninangiotensin- breathing
capillary pressure
Increased Increased Increased
aldosterone system
ventricular heart rate contraction of
(RAAS) and volume sarcomeres Air in lungs Pulmonary
edema
sympathetic system replaced by blood/
Increased strokeinterstitial fluid
have also been Small airway Rales
volume Stimulates
associated with juxta- obstruction
susceptibility to Increased end- capillary I
wheezing
consumption
*Use of cardiotoxic Right-sided HF
drugs
ENVIRONMENT
P a g e | 47
AGENT
HOST
GENES Pulmonary HTN Cor Pulmonale
*Genetic
predisposition on Right Ventricular Pressure > Left Ventricular Pressure
hypertrophic Interventricular septum bows to the left
cardiomyopathy
Prevent efficient filling of the left ventricle
(HCM) and dilated
Pulmonary congestion
cardiomyopathy
(DCM), coronary Partial obstruction of the left ventricular outflow
artery disease, Left-Sided HF
myocardial
infarction, and Increased Destruction of Hypoxia-induced Sequela to Right
hypertension afterload on the pulmonary vasoconstriction of thepulmonary ventricular
* Genetic right ventricle capillary bed pulmonary arteries disease ischemia
polymorphisms of
the Systolic Decreased Decreased Decreased Increased
reninangiotensin- dysfunction ventricular relaxation elastic stiffness of the
function recoil ventricle
aldosterone system Decreased
(RAAS) and stroke volume
Diastolic
sympathetic system Decreased dysfunction
have also been cardiac output
Increased right
associated with
ventricular end-
susceptibility to hypertrophy Increased Increased Increased diastole pressure
and/or mitigation of catecholamine preload right-sided
Congestion of
HF release Increased atrial pressure
pressure hepatic veins
* Gene variants in
the alpha-2c Increased Increased Increased
Accumulation Expansion of Impinge
ventricular heart rate contraction of
adrenoceptor and of fluid in the the liver normal
volume sarcomeres diaphragm-
the alpha-1 systemic
matic
adrenoceptor Increased stroke venous
circulation function
RACE volume
dyspnea
* African Americans Venous Distention of
liver capsule
* Hispanic/Latinos congestion
Anasarca, ascites,
* Native Americans RUQ pain
dependent edema
*Soviet Republics
AGE
*Elderly people Right-Sided HF
OTHERS
*hypertension
*hyperlipidemia
* diabetes
*CAD
LIFESTYLE
*smoking
*alcohol
consumption
*Use of cardiotoxic
drugs
ENVIRONMENT
P a g e | 48
April 22, 2010 Impaired gas exchange related to Independent: Desired Outcome:
alveolar edema due to elevated 1. R: Monitor vital signs and cardiac After 8 hours of nursing
ventricular pressures rhythm intervention, the patient was
I: for baseline data and monitoring able to demonstrate improved
Subjective cue: 2. R: Auscultate breath sounds, ventilation and adequate
“Maglisod jud ko'g ginhawa”,as I: notes areas of oxygenation of tissues by ABGs
verbalized by the patient decreased/adventitious breath within patient's normal limits
sounds and absence of symptoms of
Objective cue: 3. R:Note character and respiratory distress
>restlessness effectiveness of cough mechanism
>irritability I: ability to clear airways of Actual Outcome:
>diaphoresis secretions After 8 hours of nursing
>bilateral crackles that do not 4. R: Elevate head of bed, provide intervention, the objectives
clear with cough adjuncts and suction, as indicated were partially met. The patient
>pale skin color I: to maintain airway was able to improved
5. R: Encourage frequent position ventilation and
Scientific Analysis: changes and deep- oxygenation of tissues as
Dyspnea, or shortness of breathing/coughing exercises. Use evidenced by patient breathing
breath, may be precipitated by incentive spirometer, chest without using much of the
minimal to moderate activity physiotherapy, as indicated accessory muscle
(dyspnea on exertion [DOE]); I: promotes chest expansion and
dyspnea also can occur at rest. drainage of secretions
The patient may report 6. R: Maintain adequate I/O
orthopnea, difficulty in breathing I: for mobilization of secretions
when lying flat. Patients with 7. R: Encourage adequate rest and
P a g e | 49
symptoms. Decreased
gastrointestinal perfusion causes
altered digestion. Decreased
brain perfusion causes dizziness,
lightheadedness, confusion,
restlessness, and anxiety due to
decreased oxygenation and blood
flow. As anxiety increases, so
does dyspnea, enhancing anxiety
and creating a vicious cycle.
Stimulation of the sympathetic
system also causes the
peripheral blood vessels to
constrict, so the skin appears
pale or ashen and feels cool and
clammy.(Wolkenstein, 2000).
April 22, 2010 Excess fluid volume related to Independent: Desired Outcome:
excess fluid or NA intake and 1. R: Compare current weight After 8 hours of nursing
retention of fluid secondary to admission and/or previously stated intervention, the patient was
Heart failure and its medical weight able to stabilize fluid volume as
therapy I: provides a comparative baseline evidenced by balance I/O, vital
2. R: Auscultate breath sounds signs within patient's normal
Subjective cue: I: for presence of crackles and limits, stable weight, and free
“puno kaayo akong gibati,”, as congestion signs of edema
verbalized by the patient 3. R: Measure abdominal girth
for changes that Actual Outcome:
Objective cue: I: may indicate increasing fluid After 8 hours of nursing
>Adventitious breath retention/edema intervention, the objectives
P a g e | 53
diverted away from less-crucial R: To ensure return to normal a few Afer 8 hours of nursing
areas, including the arms and minutes after exercising. intervenions, the objectives
legs, to supply the heart and 7. I: Teach patient how to conserve were partially met. The:
brain. As a result, people with energy while performing activities of *Patient stated understanding
heart failure often feel weak daily living. of the need to perform daily
(especially in their arms and R: These measures reduce cellular activities.
legs), tired and have difficulty metabolism and oxygen demand. *Patient demonstrated
performing ordinary activities 8. I: Teach patient exercises for conservation of energy while
such as walking, climbing stairs increasing strength and endurance. performing activities.
or carrying groceries R: Improves breathing and gradually
increase activity level.
9. I: Support and encourage activity
to patient’s level of tolerance.
R: Helps patient develop level of
tolerance.
10. I: Before discharge, formulate a
plan with the patient and caregivers
that will enable the patient either to
continue functioning at maximum
activity intolerance or to gradually
increase the tolerance.
R: Participation in planning
encourages patient satisfaction and
compliance.
Pennsylvannia
Hypersensitivi
ty: ranging from
rash to fever to
anaphylaxis,
serum sickness
reaction
P a g e | 59
NSAIDs.
abdominal cramping,
acute pancreatitis,
jaundice.
Urogenital: Allergic
interstitial nephritis,
irreversible renal
failure, urinary
frequency.
Hematologic:
Anemia, leukopenia,
thrombocytopenic
purpura; aplastic
anemia,
agranulocytosis
(rare). Special
Senses: Tinnitus,
vertigo, feeling of
fullness in ears,
hearing loss (rarely
permanent), blurred
vision. Skin:
Pruritus, urticaria,
exfoliative
dermatitis, purpura,
photosensitivity,
porphyria cutanea
tarde, necrotizing
angiitis (vasculitis).
Body as a Whole:
Increased
perspiration;
paresthesias;
activation of SLE,
P a g e | 62
muscle spasms,
weakness;
thrombophlebitis,
pain at IM injection
site.
Salbutamol 1 neb
q6 To relieve bronchospasm Assessment & Drug Effects
associated with acute or Body as a Whole:
P a g e | 63
Hypersensitivity
chronic asthma, bronchitis, or reaction. CNS: • Monitor therapeutic effectiveness which is indicated
actions: other reversible obstructive Tremor, anxiety, by significant subjective improvement in pulmonary
airway diseases. Also used to nervousness, function within 60–90 min after drug administration.
Synthetic prevent exercise-induced restlessness, • Monitor for: S&S of fine tremor in fingers, which
sympathomimetic bronchospasm. convulsions, may interfere with precision handwork; CNS
amine and weakness, headache, stimulation, particularly in children 2–6 y,
moderately hallucinations. (hyperactivity, excitement, nervousness, insomnia),
selective beta2- CV: Palpitation, tachycardia, GI symptoms. Report promptly to
adrenergic agonist hypertension, physician.
hypotension, • Lab tests: Periodic ABGs, pulmonary functions, and
with
bradycardia, reflex pulse oximetry.
comparatively
tachycardia. Special • Consult physician about giving last albuterol dose
long action. Acts
Senses: Blurred several hours before bedtime, if drug-induced
more prominently
vision, dilated insomnia is a problem.
on beta2
pupils.
receptors GI: Nausea,
(particularly vomiting. Other:
smooth muscles of Muscle cramps,
bronchi, uterus, hoarseness.
and vascular
supply to skeletal
muscles) than on
beta1 (heart)
receptors. Minimal
or no effect on
alpha-adrenergic
receptors. Inhibits
histamine release
by mast cells.
Aldozide 1 tab BID Essential hypertension, Gynecoma • ducate patient to avoid hazardous activity such as
edema and ascites of stia, GI driving until response to drug is known.
P a g e | 64
CHF, liver cirrhosis, symptoms • Take with meals or milk; avoid excessive ingestion
nephritic syndrome, , lethargy, of food high in potassium or use of salt substitutes
Mechanism idiopathic edema headache • Diuretic effect may be delayed 2-3 days and
of Action: : and maximum hypertensive may be delayed 2-3weeks;
competes thrombocy monitor I and O ratios and daily weight, BP, serum
with topenia, electrolytes (K, Na) and renal function
aldosterone leukopeni
for receptor a,
sites in the agranuloc
distal renal ytosis,
tubules, cutaneous
increasing eruptions,
sodium pruritus,
chloride and mental
water confusion,
excretion paresthesi
while a, acute
conserving pancreatiti
potassium s,
and jaundice,
hydrogen orthostati
ions, may c
block the hypertensi
effect of on,
aldosterone muscle
on arteriolar spasm,
smooth weakness,
muscle as fever,
well ataxia
P a g e | 65
Exercise Regularly scheduled, moderate exercise A - Assess patient’s understanding of exercise regimen.
and performed for at least 30 minutes most days
I - Explain the importance of exercise:
Environme of the week promotes the utilization of
nt carbohydrates, assists with weight control, • Caloric expenditure for energy in exercise
enhances the action of insulin, and improves • Carryover of enhanced metabolic rate and efficient food
cardiovascular fitness. utilization
- Advise patient to assess blood glucose level before and after
strenuous exercise.
Treatment Teach patients the appropriate technique for A - Assess if the patient is continually sticking to V/S monitoring
testing blood and urine and how to interpret schedules and treatment regimen.
the results.
I - Patients need to know when to notify the physician and increase
testing during times of illness.
Stress the importance of close attention to − In addition, teach patients to avoid crossing their legs when
even minor skin injuries. sitting and to begin a regular exercise program.
Health If the patient continues to smoke, provide A - Assess for the patient’s ability to do self-care
Teaching the name of a smoking cessation program or
- Assess patient’s will or degree to decrease/ cease smoking.
and a support group. You follow the same
P a g e | 67
Hygiene protocol for drinking to avoid other diseases. I - Discuss concerns with parent to identify underlying issues
Out Patient Note any referrals to social services. Remind A - Assess for signs and symptoms
follow-up for follow-up schedule. Call if appropriate.
- Assess the understanding of the parent as to the possible reason
and
for follow-up visit
Observatio
n I - Instruct patient/ SO to refer immediately to physician if health
condition worsens
Diet Emphasize the importance of adjusting diet A - Assess foods in compliance to given diet
during illness, growth periods, stress, and
-Assess patient’s preference of food
pregnancy.
I - Instruct patient to watch for timing of food and not to eat more
P a g e | 68
than necessary.
Spiritual Provide emotional and spiritual support. A - Assess patient’s readiness to be involved in such activities
XIII. Bibliography
PPD's Nursing Drug Guide, 2nd Edition. Pasig: Medicomm Pacific, Inc.,
2008.
***